A nurse is receiving information about four children during change-of-shift report. Which of the following children should the nurse assess first?
A 12-year-old child who has cystic fibrosis and reports difficulty clearing secretions
A 3-year-old child who has an atrial septal defect and a heart rate of 120/min
A 5-year-old child who has type 1 diabetes mellitus and a blood sugar of 150 mg/dL
A 2-year-old child who has diarrhea and reports abdominal pain
The Correct Answer is A
A. A child with cystic fibrosis and difficulty clearing secretions is the priority because airway clearance is critical in cystic fibrosis. Mucus buildup can lead to respiratory distress and infection, requiring immediate intervention.
B. A child with an atrial septal defect and a heart rate of 120/min is not the priority because a heart rate of 120/min is within the expected range for a 3-year-old and does not indicate immediate distress.
C. A child with type 1 diabetes and a blood sugar of 150 mg/dL is not the priority because this blood glucose level is slightly elevated but not critical.
D. A child with diarrhea and abdominal pain requires assessment, but dehydration or electrolyte imbalance develops over time. Airway issues take priority over gastrointestinal symptoms.
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Related Questions
Correct Answer is C
Explanation
A. Rotavirus vaccine is for infants, not older adults. It is given to prevent severe diarrhea caused by rotavirus.
B. Human papillomavirus (HPV) vaccine is recommended for adolescents and young adults, typically before age 26, to prevent cervical and other cancers.
C. Herpes zoster (shingles) vaccine is recommended for older adults, usually starting at age 50 or 60, to reduce the risk of shingles and its complications.
D. DTaP is given to infants and young children. Instead, older adults should receive a Td or Tdap booster every 10 years.
Correct Answer is D
Explanation
A. Antibiotic therapy. This is incorrect because there is no indication of an infection. The WBC count is within the normal range, and there are no symptoms suggestive of a bacterial infection.
B. Protective environment. This is incorrect because a protective environment is used for immunocompromised clients, such as those undergoing chemotherapy or with severe neutropenia, which is not the case here.
C. Blood transfusion. This is incorrect because although the hemoglobin level is low (8.1 g/dL), it is not critically low enough to require a transfusion. Instead, iron supplementation is the preferred treatment.
D. Iron supplementation. This is correct because the child’s hemoglobin and hematocrit levels indicate mild anemia, likely due to excessive cow’s milk intake, which can lead to iron deficiency anemia in toddlers. Iron supplementation will help correct the deficiency.
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